ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. When a nurse is interviewing a client who is requesting oral contraceptives, which finding in the client’s history is a contraindication to combined oral contraceptives?
- A. Thyroid disease
- B. Allergy to penicillin
- C. Impaired liver function
- D. Abnormal blood glucose levels
Correct answer: C
Rationale: The correct answer is C: Impaired liver function. Impaired liver function is a contraindication to the use of oral contraceptives because they are metabolized in the liver. Choices A, B, and D are incorrect. Thyroid disease, allergy to penicillin, and abnormal blood glucose levels are not contraindications to combined oral contraceptives.
2. A nurse in the emergency department is prioritizing care for four clients. Which of the following clients should the nurse see first?
- A. A 6-year-old with a dislocated shoulder
- B. A 26-year-old with sickle cell disease and severe joint pain
- C. A 76-year-old with confusion, fever, and foul-smelling urine
- D. A 50-year-old with slurred speech, disorientation, and headache
Correct answer: D
Rationale: The client with slurred speech, disorientation, and a headache may be experiencing a stroke, a life-threatening condition that requires immediate attention. Identifying and managing a stroke promptly can reduce the risk of long-term disability or complications. The other options, although important, do not present immediate life-threatening conditions that require urgent intervention. A dislocated shoulder, severe joint pain in sickle cell disease, confusion with fever and foul-smelling urine, while concerning, can be addressed after attending to the client with potential stroke symptoms.
3. While caring for a client receiving patient-controlled analgesia (PCA), which of the following interventions should the nurse take?
- A. Encourage the client to use the PCA before dressing changes.
- B. Monitor the client's respiratory status.
- C. Provide oxygen therapy to the client as needed.
- D. Ensure the PCA pump is functioning properly.
Correct answer: A
Rationale: Corrected Rationale: The nurse should encourage the client to use the PCA pump before activities like dressing changes, which are likely to cause pain, to ensure effective pain management. Monitoring the client's respiratory status (Choice B) is important but not the priority in this scenario. Providing oxygen therapy (Choice C) is not a routine intervention for all clients on PCA unless specifically indicated. Ensuring the PCA pump is functioning properly (Choice D) is essential, but encouraging the client to use the PCA before painful activities takes precedence to manage pain effectively.
4. A nurse is caring for an older adult who has a non-palpable skin lesion that is less than 0.5 cm in diameter. Which term should the nurse use to document this finding?
- A. Vesicle
- B. Macule
- C. Papule
- D. Nodule
Correct answer: B
Rationale: The correct answer is B: Macule. A macule is a non-palpable skin lesion smaller than 1 cm in diameter. In this case, the skin lesion described is less than 0.5 cm, making it consistent with a macule. Vesicle (choice A) is a small blister filled with clear fluid, papule (choice C) is a solid, raised skin lesion less than 0.5 cm in diameter, and nodule (choice D) is a palpable, solid lesion larger than 0.5 cm in diameter. Therefore, choices A, C, and D describe skin lesions that do not match the characteristics of the lesion presented in the question.
5. A client with a history of asthma is being cared for by a nurse. Which of the following should the nurse monitor?
- A. Heart rate
- B. Respiratory status
- C. Blood glucose levels
- D. Liver function
Correct answer: B
Rationale: The correct answer is B: Respiratory status. When caring for a client with asthma, it is essential to monitor their respiratory status to detect any changes in breathing or signs of airway obstruction. Monitoring heart rate (choice A) may be important in some situations but is not the priority when managing asthma. Blood glucose levels (choice C) and liver function (choice D) are not directly related to asthma and would not be the primary focus of monitoring for a client with this condition.
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